Simple Interventions and Reducing Risks
Overview of the importance of simple interventions
Lower respiratory tract infections (LRTIs) were the 4th biggest cause of death globally in 2016.1 Non-tuberculous mycobacterium (NTM), a type of LRTI, is associated with increased mortality,2 yet testing rates are both low and variable despite guideline recommendations.3 So with low testing and high mortality, why aren’t we doing more?
With occupancy levels within the National Health Service (NHS) increasing,4 and occupancy levels within some trusts frequently reaching dangerous levels,5 it seems it’s time to establish a plan. Hospital admissions for respiratory disease have risen at three times the rate of all hospital admissions generally,6 meaning respiratory diseases are not something to be overlooked.
What can we do to help?
Non-tuberculous mycobacterium (NTM) are a group of bacteria, capable of causing lower respiratory tract infections (LRTIs).9 Patients with an underlying respiratory disease will be more susceptible to infections caused by NTM. NTM pulmonary disease (NTM-PD) is often underdiagnosed, with patients showing symptoms similar in nature to those caused by existing lung diseases.10 11 The diagnosis of NTM-PD is often missed or delayed until the disease is already in moderate to severe stages,12 which can lead to severe consequences and disease progression. Over an average of 6 years, 97.5% of untreated nodular bronchiectatic Mycobacterium avium complex (MAC) pulmonary disease patients experienced radiographic disease progression, after receiving no early interventional treatment due to minimum symptoms.13 Although this was a small study investigating only 40 patients, the outcomes show how serious NTM-PD can be. Alongside this, patients who are not diagnosed early enough and left untreated can have a decline of lung function, a worsening of symptoms such as chronic cough, fatigue, malaise and fever, and a decreased health-related quality of life.14 15 16
In the same way that common respiratory infections are easy to test for, NTM is too. Pneumonia testing, for example, uses techniques such as sputum tests, chest x-rays, pulse oximetry, blood tests.17 The main methods used to test for NTM include sputum, induced sputum, bronchial washings, bronchoalveolar lavage or transbronchial biopsy samples, with guidelines recommending use of less invasive methods first.18 Early intervention with testing and treatment for NTM-PD can help to prevent disease progression.19 To prevent the emergence of macrolide-resistant mycobacterium avium complex (MAC) strains, which are associated with increased mortality, it is important that patients receive a multidrug regimen as the first line treatment.19 10
Recommended treatment options are found in the British Thoracic Society (BTS) Guidelines, which recommend an intermittent regimen, based on the severity of the disease and treatment tolerance.18 Patients with NTM-PD often do not receive the appropriate treatment options with around half of patients in primary care not receiving guideline-based therapy, and 14% of patients receiving no treatment at all.20 NTM MAC patients who didn’t receive treatment had a significantly higher mortality rate, compared with NTM MAC patients who did receive treatment.21
So, what now?
With occupancy rates frequently above 90% leaving little spare capacity, hospitals are struggling to accommodate sudden and unpredictable increases in emergency admissions.7 LRTIs being one of the most common causes of emergency admissions in the winter months combined with the fact that LRTIs are a prominent cause of death globally,5 22 demonstrates the fact that simple interventions should be implemented to reduce the extra pressures caused by LRTIs. These include early use of guideline based therapy and encouraging testing for all types of LRTI including NTM. Testing is crucially important as it enables identification of patients with NTM, who can then be treated with the recommended multidrug regimen in the first instance. If NTM is excluded, macrolide monotherapy could be prescribed, if appropriate, without fear of resistance developing.